0:12Skip to 0 minutes and 12 seconds[DR SUSANNAH WOODD]:: We'll start this course on maternal health by taking a look at the epidemiology of maternal mortality and morbidity. We'll look at important changes in the past 25 years and what maternal health looks like today. So over the last 25 years, the period of the Millennium Development Goals, national and global efforts to improve maternal health have led to a substantial decrease in mortality, from approximately 532,000 deaths in 1990 to just over 300,000 in 2015. However, as can be seen in the graph, the vast majority of these deaths continue to occur in low- and middle-income countries. Sub-Saharan Africa accounts for two-thirds of the deaths.

0:55Skip to 0 minutes and 55 secondsAnd there are particular countries, such as Nigeria and India, that partly due to their large populations, but also their high mortality rates, contribute to a substantial proportion of the overall deaths. However, while maternal mortality remains an important health concern and an ongoing focus in the current era of Sustainable Development Goals, it is only a small part of the picture of maternal health. We estimate that 27 million episodes of potentially life threatening, direct obstetric morbidity occur annually. 140 million babies are born, and over 200 million women become pregnant. Each of these women requires good quality health services to ensure both their own safety and that of their baby. So what are the threats to women's health?

1:45Skip to 1 minute and 45 secondsWell, globally, direct obstetric causes remain the most important reason for death. Haemorrhage alone leads to over a quarter of all deaths. And hypertensive disorders, sepsis, and complications of abortion account for another third. However, when we consider morbidity, a different picture emerges. The WHO has identified 121 diagnostic categories of maternal morbidity. That's a huge breadth to the burden. But in addition, the pattern of these conditions is different to that seen with mortality. So postpartum haemorrhage is still important, affecting over 10% of women. But it's possible that the same proportion of women suffer from gestational diabetes, a condition that causes too few deaths to appear as a separate condition on the previous graph.

2:34Skip to 2 minutes and 34 secondsBut it does require careful management to avoid poor pregnancy outcomes, such as stillbirth. And it's a risk for developing diabetes later in life. Similarly, depression carries a low mortality rate, but is estimated to affect up to 60% of women, impacting not only on the woman's own health, but also her ability to care for her baby. So you can see that maternal health is a far larger, broader, and more complex issue than the initial overview of mortality suggests. There are also complexities to the way maternal health is changing. Overall, as we've seen, mortality is reducing.

3:14Skip to 3 minutes and 14 secondsBut alongside that are shifts in the environment, such as increasing urbanisation, increased wealth, and education, as well as changes in the demographics of pregnant women themselves. This results in what is described as the obstetric transition, leading to reduced fertility, fewer overall deaths, but at the same time a lower proportion of deaths from direct obstetric causes and a proportionate increase in indirect mortality. We can see that illustrated here, comparing the change in mortality from haemorrhage, the largest single reason for maternal death, and deaths from indirect causes. Throughout the world, the percentage of deaths from haemorrhage has dropped between 1990 and 2013, while those from indirect causes have increased. However, this has happened at different rates in different regions.

4:08Skip to 4 minutes and 8 secondsThere's very little reduction in the importance of haemorrhage in sub-Saharan Africa and a higher increase in the proportion dying from indirect causes in high-income countries and Latin America compared to other regions. It's important to note that these are only the percentage of deaths from each cause. So while the proportion of indirect deaths is increasing, the actual mortality rate is falling in many regions. However, in high-income countries, the rate of death from indirect causes has increased. Cardiovascular disease is now the single largest cause of maternal death in the United Kingdom, Australia, and the United States. And it's very likely that the obstetric transition described would drive up indirect causes of mortality and certainly morbidity elsewhere.

4:58Skip to 4 minutes and 58 secondsWomen are increasingly starting their families at an older age when their fertility is lower, there are higher risks involved in giving birth, and a greater chance of genetic disorders in the child. At the same time, increased wealth and an urban lifestyle is contributing to the global obesity crisis. Around 15% of women in the world are now considered obese. That's more than double the proportion seen 40 years ago. And in some regions, the issue is even bigger. The red areas on the map show countries where over a quarter of adult women are obese. Obesity is thought to be one of the drivers of the increased maternal mortality rate seen in the United States.

5:40Skip to 5 minutes and 40 secondsIt's linked to hypertension and cardiac disease and is a known risk factor for gestational diabetes and postpartum wound infections. And alongside health outcomes related to these socioeconomic and demographic changes, we have also seen shifts in the role of infectious diseases. Physiological changes in pregnancy reduce immunity and increase the risk of both developing many infections and of progressing to more severe disease. For example, the H1N1 flu pandemic of 2009 caused a peak in maternal deaths, illustrated here in Mexico and highlighted in the United Kingdom Confidential Enquiry into Maternal Deaths. Control programmes have reduced the incidence of malaria, but climate change and globalisation are probably driving the spread of dengue across the world and now the emergence of Zika.

6:33Skip to 6 minutes and 33 secondsAnd over the last 25 years, HIV testing and management has become an integral part of maternal health care in many regions. When we look at the profile and changes in maternal health, there's an increasing diversity in health conditions both within and across countries and regions. But alongside this diversity in conditions, there is also a diversity in the care women receive, their ability to access any care, and the quality of that health care. Now, we discuss this issue of access later this week. And we'll focus on widening inequalities in quality of care in week two. But I mention this variation in coverage of care now because it plays a significant role in the inequity we see in maternal morbidity and mortality.

7:23Skip to 7 minutes and 23 secondsAs already shown, the overall trend for maternal mortality is positive, with large global and regional reductions. But this can mask huge disparities between and within countries. And there is evidence that the gap is becoming wider. When we consider the 10 countries with the highest maternal mortality, the blue line at the top of the graph, they now have over 200 times the mortality rate of the 10 best performing countries, the line at the bottom. And this relative difference, shown in red, has doubled since 1990. So there is a divergence in the burden of maternal mortality, a burden that's particularly high in sub-Saharan Africa, among the poor, and in the most vulnerable populations.

8:11Skip to 8 minutes and 11 secondsAnd alongside this, there is an increasing diversity in the health problems and needs of pregnant women across the world. This diversity presents challenges to providing good, appropriate health care for all pregnant women and their babies. But it also presents opportunities. It means that one size can no longer fit all, but local understanding and experience, including women's own perspectives, is necessary to drive improvements in maternal health care and in maternal health.

The global profile of maternal mortality and morbidity

What is the current epidemiology of maternal health, and how has it been changing over time?

In this step Dr Susannah Woodd (LSHTM) provides an overview of the numbers of deaths and burden and range of morbidity in maternal health. We explain the greater prominence of the indirect causes of ill-health, compared to direct ones. We end by describing the increasing diversity in the health problems and needs of pregnant women globally, together with a divergence in the burden of mortality, seen especially in sub-Saharan Africa, and in the most vulnerable populations.